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					                      PROCESS FOR BECOMING A MEDICARE
                       CERTIFIED RURAL HEALTH CLINIC

This checklist will help guide your clinic to become certified as a Rural Health Clinic
(RHC) under the Medicare program. There are three main steps to become certified as a
RHC. Each step is comprised of many elements. All steps must be met before RHC
certification is granted.

If you have any eligibility or application questions contact:

       Laura Olexa
       Department of Health
       Office of Community and Rural Health
       PO Box 47834
       Olympia, WA 98504-7834
       Phone: 360-236-2811
       Fax: 360-664-9273

For all other questions please contact:

       John Hanson
       Department of Health
       Office of Community and Rural Health
       PO Box 47834
       Olympia, WA 98504-7834
       Phone: 360-236-2819
       Fax: 360-664-9273

       Step # 1 – Establish initial eligibility. Clinics are eligible if they:

           A. Are located in a rural or non-urbanized community as defined by the Census Bureau. The
              Office of Community and Rural Health (OCRH) will request verification of your clinic’s
              location from Centers for Medicare and Medicaid Services (CMS).

           B. Are located within a federally designated primary care Health Professional Shortage Area
              (HPSA) or Medically Underserved Area (MUA). This designation must be current
              within three (3) years of the date of the clinic’s on-site survey.

       Step #2 – Prepare for on-site survey. All steps must be completed prior to the survey
                being scheduled by Facilities and Services Licensing (FSL).

           A. Review on-site survey criteria including:
               Rural Health Clinic Medicare Regulations (current)
               Rural health Clinic Survey Report Form – CMS 30
               Appendix G Rural Health Clinic Interpretive Guidelines

           B.   CMS 855 – General Enrollment form. You need to request this form from one of the
                fiscal intermediaries listed below. Simply fill out the CMS 855 and return it to the fiscal
                intermediary for processing (not the Department of Health). Processing of this form can
                take up to 60 days. No survey will be scheduled until the fiscal intermediary has

May 12, 2006
Page 2

CMS 855 – General Enrollment form continued

        submitted your form to Facilities and Services Licensing (FSL). Please note: FSL has 60
        days from receipt of your CMS 855 form with which to schedule your survey.

        For clinics that are freestanding:              For clinics that are provider based:
        Riverbend GBA                                   Noridian Mutual Insurance Company
        730 Chestnut Street, Room 3C                    PO Box 6700
        Chattanooga, TN 37402-1790                      Fargo, ND 58108
        1-423-755-5124                                  1-888-608-8816

   C. Employ a medical director available to provide patient care at least once in every two-
      week period.

   D. Employ a nurse practitioner, certified nurse midwife or physician assistant to provide care
      at least 50% of the time the clinic is open.

   E.   Identify an individual in the clinic who is responsible to assure that all the Medicare
        Conditions for Certification are met as listed in the Rural Health Clinic Regulations. This
        designated individual should be thoroughly versed in all of the RHC Conditions for
        Certification and all aspects of clinic services.

   F.   Develop a RHC manual that includes all required policies, procedures and protocols as
        listed in the Rural Health Clinic Regulations.

   G. Develop written job descriptions for the physicians and mid-level practitioners. Be sure
      the job descriptions include responsibilities for policy and procedure development and
      participation in program evaluation activities.
   H. Review all employee file information for evidence of current licensure, DEA number for
      professional providers and other required certification and training.

   I.   Determine if the clinic’s physical plant and environment meet all federal, state and local
        safety and maintenance requirements as listed in the Rural Health Clinic Regulations.
        This includes medication management systems, fire & safety codes, physical plant
        maintenance, storage of cleaning supplies, patient care equipment calibration &
        maintenance, etc.

   J.   Assure the clinic is able to provide all six required lab tests on the clinic’s premises and
        have appropriate MTS/CLIA waiver available for surveyor to review during onsite
        survey. Go to for MTS (medical test
        site) waiver information and application.
   K. Develop a written program evaluation or quality improvement program that meets the
      requirements listed in the Rural Health Clinic Regulations.
   L.   Make all necessary actions to assure the clinic meets all of Conditions for Certification as
        listed in the Rural Health Clinic Regulations.

May 12, 2006
Page 3

          Step # 3 – On-site Survey
    A. After all the requirements in Step #2 have been met complete and submit the following
       forms to Laura Olexa (contact information can be found above):

                   Request for On-Site Survey
                   Request to Establish Eligibility – CMS 29
                   Health Insurance Benefits Agreement – CMS 1561A (three copies with original
                    signatures on each)

    B.    A Facility and Services Licensing Surveyor will contact you to verify that you consider
          your clinic meets all of the Medicare Conditions for Certification and to schedule the on-
          site survey. If you have any questions about your surveyor, contact Raejean Bales at 360-
    C. Upon completion of the on-site survey your clinic will receive a written report indicating
       if the clinic meets all the Conditions for Certification and a recommendation from the
       State that the clinic be approved to participate in the Medicare RHC program. If the clinic
       is found to have any deficiencies corrections must be made before the clinic is
       recommended for approval. NOTE: If the clinic does not meet one or more of the
       Medicare Conditions for Certification the clinic cannot be certified. You will be
       given an opportunity to resolve these deficiencies within a reasonable amount of
       time before being surveyed again.
    D. Survey information is forwarded to CMS Region X office in Seattle by FSL with a
       recommendation for approval to participate in the Medicare Rural Health Program. CMS
       is responsible for the final certification decision.

    E.    CMS Region X office will notify the clinic of approval status, within 30 days, of the
          clinic’s Medicare provider number and effective date. That office may be contacted at:
          (206) 615-2350.

    F.    The clinic contacts the fiscal intermediary regarding billing instructions after receiving the
          provider number.

    G. After the clinic has been approved, the provider should contact the fiscal intermediary
       regarding Medicare billing instructions. To establish a Medicaid Billing Number and rate
       contact the Washington State Medical Assistance Administration.

          Irina Lusby, RHC Program Manager
          Office of Professional Rates
          Health and Recovery Services Administration
          (360) 725-1882

    H. The Department of Health - FSL will make periodic unannounced inspections to assure
       the clinic continues to meet all Medicare Conditions for Certification.

S:/Rural Health Clinic/Application Packet Forms/RHC Process 5/12/2006


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